Focus moves to divisive issues of health and pensions

Obama has given priority to the moral imperative of covering more people. Romney says costs must be brought under control before coverage can be extended.

Up to 45 million additional people would be covered under Obamacare, mainly by expanding Medicaid – government insurance for the poor and disabled – to those with an income 138 per cent of the poverty level or less. Everyone over 138 per cent will be required to purchase healthcare insurance or pay a fine. It is this “individual mandate” – deemed a tax by the Supreme Court – that Republicans hate most about Obamacare.

Obamacare also attempts to control costs by paying healthcare providers less for services and by decreasing utilisation. One major concern, emphasised by Romney in his criticism of Obamacare, is that providers will refuse to treat Medicare and Medicaid patients if reimbursement is inadequate.

“The US system does many more MRIs, CAT scans and surgeries than other countries, because we have a fee-for-service reimbursement system that incentivises doctors and hospitals incentives to do more,” said Dr Karpf.

Europeans have a different attitude towards end-of-life care, Dr Karpf added. “They understand that death is not optional, whereas in the US the fee-for-service system drives continuing care. Europeans wouldn’t do heart surgery on a 92-year-old.”

Dr Karpf has a lifetime’s experience in oncology, internal medicine and public health. The only option for the future, he said, is to “minimise the amount of services provided but maximise outcomes”. This will be done, he predicted, through more efficient “bundling”, “longitudinal care” and “capitation” or grouped billing systems.

He cited the healthcare company Kaiser Permanente, which cares for four million people in California, as “the direction this country will go under Obamacare, and eventually under the Republicans.”

In the system Dr Karph envisages, companies such as Kaiser will receive set fees per patient each year, and will lose money if inefficient. Patients will be able to compare mortality and complications rates in competing systems, incentivising providers not to skimp on quality. “It requires a cultural change, and will take decades, not years,” he said.

Democrats want to maintain Medicare benefits, regardless of rising costs, while Republicans are determined to limit those costs to a defined level. Romney-Ryan would give Medicare patients the option of purchasing alternative, private plans with government vouchers. Vice-president Biden has labelled it “voucher care”. Because “voucher” has a negative connotation, Republicans have begun calling it “premium support” instead.

Far less attention has been paid to Medicaid – where policies are radically different – probably because the poor are a less vocal voting group than senior citizens. Ryan has proposed cutting $810 billion (€626 billion) from Medicaid over a decade, while Obamacare would increase the Medicaid budget by $642 billion (€497 billion) for the same period.

The Supreme Court’s ruling that states cannot be forced to expand Medicaid coverage is a serious threat to Obamacare. Some governors, such as Jerry Brown in California, say they’ll find a way regardless of their finances. “No way,” said Texas governor Rick Perry. More than a dozen talk of opting out.